=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699045740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR SHRESTHA MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2012
-----------------------------------------------------
Last Update Date | 01/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1050 M L KING DR SUITE 111
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-3060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-868-4507
-----------------------------------------------------
Fax | 877-397-7287
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 SABLE DR
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-4472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-868-4507
-----------------------------------------------------
Fax | 877-395-7287
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NIRANJAN SHRESTHA
-----------------------------------------------------
Credential | MD, FAAFP
-----------------------------------------------------
Telephone | 567-868-4507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------